Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, July 27, 2017

The Republican War on Reality, continued

Two essays in the new NEJM worth your attention. R.A. Charo discusses the anti-science of the anti-abortion movement. Some of this is a bit complicated, and I suggest you read it rather than relying on my summary. But the starting point for much of it is the fact that about half of all blastocysts fail to implant. If life begins at conception, that means that God murders 50% of all babies who are ever conceived. When this happens, the woman never even knows that she was, in the terms of the anti-abortion movement, "pregnant." She just has a normal menstrual period.

Ergo, if you believe that a blastocyst is a human being with all the rights of a person, that the death of an embryo is morally indistinguishable from the death of a baby, and that destroying embryos is murder, you are compelled to believe that the spontaneous death of 50% of all embryos is the greatest public health crisis conceivable (sic). You are compelled to believe that it should be the highest national imperative to pour money into research and interventions to stop this holocaust. But you don't believe that, because you don't really believe that embryos are the moral equivalent of babies. Your movement must be about something else.

Now we have Henry Aaron and colleagues. (No, not Hammering Hank, rather the health care economist.) Why have some health insurers pulled out of the ACA exchanges, why do a few rural counties have no participating insurers, and why have some requested substantial premium increases? Republicans claim it's because the ACA is "failing" due to inherent flaws in design, but this is not, you know, true.

Some insurers did initially set premiums too low because they didn't know enough about the characteristics of what would become the newly insured. When they subsequently raised premiums this was an adjustment, to be sure, but it did not result in sharp enrollment declines, and markets were set to stabilize in 2017. But as soon as the new president took office, he immediately set out to undermine the ACA.

On his first day in office, Trump signed an executive order
directing his administration to be as permissive as possible in
providing exemptions from ACA provisions, including the individual
mandate. Then the House of Representatives passed the American Health
Care Act, which would repeal the individual mandate retroactive to plan
year 2016. The Congressional Budget Office estimates that the resulting
exodus of healthier enrollees from the individual market would drive a
20% increase in individual market premiums for 2018.3The
President has also sown doubt about whether the federal government will
continue to reimburse insurers for cost-sharing subsidies that they are
legally required to provide to most marketplace enrollees. . . .

The Kaiser Family Foundation estimates that ending the payments would
require insurers to raise premiums for “silver” plans by 19% on average
across states using the HealthCare.gov enrollment platform.4 These
steps have been all the more damaging because they appear to be part of
a deliberate strategy to undermine the ACA. President Trump has noted
that withholding cost-sharing reduction payments could seriously damage
the individual market and that market turmoil increases his leverage in
seeking repeal of the ACA. To that end, the administration reportedly
opposed adding language to recent appropriations legislation giving it
clear legal authority to continue the cost-sharing reduction payments.

Faced
with these risks, some insurers are abandoning the individual market.
Anthem, one of the country’s largest insurers, cited policy uncertainty,
especially regarding cost-sharing reduction payments, as a major factor
in its decision to leave Ohio’s market.

Now, about that individual mandate and "freedom." This is very simple. If insurers are required to cover people with pre-existing conditions, then people who are healthy can just not buy insurance until they get sick. This makes insurance more expensive, so people who are just a little bit sick won't buy it, so it gets even more expensive and so it goes until nobody can buy insurance. The whole point of insurance is that you buy it in case you will need it. You are not allowed to wait until your house is on fire to buy homeowner's insurance which will cover you for said fire, and you are not allowed to wait until you wreck your car to buy auto insurance which will cover you for said car wreck.

Most Americans have no quibble
with Obamacare itself, but for Republicans, repealing it is and always
has always been a way to repudiate former president Barack Obama. Since
taking office, President Trump has done several things that he
previously chastised Obama for, but these contradictions
have had little impact on his party or their supporters. This is
largely because GOP voters’ disdain for Obama and support for Trump
cannot be separated from findings about racism. Studies
conducted after the election confirm that racial resentment directed
toward people of color predicted both overall support for Trump and
voters’ propensity to switch from Obama to Trump.
GOP voters know
they don’t like Obama, but they do not know Obama’s legislative record,
whether it pertains to the economic recovery or health care legislation.
A December 2016 poll
showed that 67 percent of Trump voters believed that unemployment had
risen during Obama’s tenure, even though it dramatically declined. A
February 2017 poll found that one third of all Americans did not even
know that Obamacare and the Affordable Care Act were the same thing.
Over half of the Republicans in that poll did not know whether Medicaid
would be impacted by repealing Obamacare. Medicaid will be gutted by
the new bill.

So the naked truth is that racial resentment
directed toward Obama set off a chain of events that will likely cause
20 million people to lose their health insurance and ignite a public
health crisis of unimaginable consequence. Some time ago, I wrote
about one of the myths of white supremacy: the idea that its ill
effects are limited to targeted groups. I explained, “What white
supremacy does, eventually, is normalize and spread the abuse, trauma,
and destruction initially prescribed for targeted groups.” The damage
prescribed by hateful ideologies is most severe within targeted groups,
but it is never contained.

2 comments:

For most of it's existence, Obamacare has had very low approval. Just recently it's stuck its head up above the 50% mark.

If the ACA law was so poorly conceived and written...so dependent on a friendly incoming executive branch to survive, what kind of legislation is that, really?

To blame the demise that you say isn't happening on this new administration is absurd. This law was designed to fail. Progressive Democrats just gambled on retaining power in the next election and thought they could transition into a single payer government run healthcare system. They gambled and they lost.

They never counted on losing power. They had no plan B.

MIT economics professor Jonathan Gruber infamously told an audience at the University of Pennsylvania in November 2014 that Democrats required “the stupidity of the American voter” for Obamacare to become law.

Man, what a night. I turned off my phone. Thanks, John McCain! You just saved that lying scoundrel, Mitch McConnell, from killing his constituents. It was just stunning to see MM lying his ass off afterward about what a big favor he was trying to do for Americans--killing them, that is--and how the ACA limited choices and caused skyrocketing costs.